Understanding the epidemiological HIV risk factors and underlying risk context for youth residing in or originating from the Middle East and North Africa (MENA) region: A scoping review of the literature

Introduction HIV is the second leading cause of death among young people globally, and adolescents are the only group where HIV mortality is not declining. Middle East and North Africa (MENA) is one of few regions seeing rapid increase of HIV infections (31.0%) since 2001. MENA youth are at particular risk of HIV due to dearth of research and challenges in accessing services. Objective The purpose of this scoping review is to establish the epidemiological HIV risk factors and underlying risk context for youth residing in or originating from the MENA region. Methods Online database searches were conducted using combination of search terms. Screening 5,853 citations, published between 1990–2019 with age groups 16 to 29, resulted in 57 studies included across 18 MENA countries. Results ‘Key populations’ engage in risky behaviors, including: overlapping risky behaviors among youth who inject drugs (PWID); lack of access to HIV testing, condomless sex, and multiple sex partners among young men who have sex with men (MSM); and high and overlapping risk behaviors among young sex workers. Challenges facing other youth groups and bridging populations include: peer pressure, inhibition about discussing sexual health, lack of credible sex education sources, low condom use, and lack of access to HIV protection/prevention services, especially testing. Conclusion Poor surveillance coupled with scarcity of rigorous studies limit what is known about epidemiology of HIV among youth in MENA. Homophobia, stigma around PWID, and illegal status of sex work promote non-disclosure of risk behaviors among youth and curtail serving this population.


Introduction
Young people and adolescents are disproportionately impacted by the HIV epidemic globally. Indeed, as of 2019, 1.6 million people aged between 10 and 19 years are living with HIV and 190,000 are newly infected [1]. In fact, HIV is the second leading cause of death among young people globally, and adolescents are the only group for which mortality from HIV is not declining [2].
With a steadily growing youth population, the Middle East and North Africa (MENA), which we define to include 18 countries with common socio-historical, linguistic and religious characteristics, is home to 80 million youth. Its young adult population make up 10% of the world's population [3,4]. Despite having the lowest HIV prevalence in the world (less than 0.1%), the Middle East is one of few regions where the HIV epidemic has not waned and in fact, is increasing at a rapid rate; with a 31.0% increase of HIV infections since 2001, it has seen the highest documented increase among all regions in the world [5]. In part due to poor access to antiretroviral treatment (ART) as well as the significant presence of homophobia and discrimination based on sexual orientation and gender identity, AIDS-related deaths increased in the region by 66.0% between 2005 and 2013 at a time when global AIDS-related deaths fell by 33.0% [6].
Mirroring global HIV transmission patterns-with the exception of Sub-Saharan Africa where generalized population epidemics are predominant-the HIV epidemic in MENA has primarily affected people who inject drugs (PWIDs), men who have sex with men (MSM), and female sex workers (FSWs), commonly referred to as 'key populations'. Additionally, other groups-known as 'bridging populations' have been impacted-albeit to a much lesser extent compared to key populations. These groups, such as clients of sex workers-are commonly behind the transmission of HIV/STIs from high-risk core groups to noncore groups, linking key populations with the general population [7].
Notwithstanding the heterogeneity in risk behaviors and risk contexts that characterize the MENA region, two predominant patterns can be noted with respect to the spread of HIV across the region. On one hand, there are countries where HIV prevalence is substantial; where a state of generalized HIV epidemics-defined as HIV rates consistently greater than 1% among pregnant women-applies to parts of Somalia, Djibouti and Southern Sudan [8]. In these contexts, HIV infections are most common among key and bridging populations. The second group are countries with a low HIV prevalence, and these represent the majority of MENA countries [3,8]. In the latter group, concentrated epidemics-defined as an epidemic with an HIV prevalence greater than 5.0% in a key population-have been documented in several countries. For example, there is evidence for concentrated epidemics among PWIDs in some MENA countries, and emerging evidence for potential concentrated epidemics among MSM. In this group of countries, however, there is no evidence for concentrated epidemics among FSWs or epidemics in the general population [3,8].
Little is known about the epidemiology of the HIV epidemic in the region. Poor surveillance coupled with a dearth of rigorous studies in the scientific literature limit what is known about the epidemiology of HIV. Illustratively, a study assessing HIV surveillance systems in the region has found that only four of 23 MENA countries had proper systems to enable them to estimate patterns of HIV epidemics [9]. Moreover, perceptions of HIV through a 'prism of sin', including significant homophobia, have promoted non-disclosure of risk behaviors and curtailed the emergence of organizations to serve populations at risk [10].
Against this backdrop, a review of the literature on HIV among young populations in MENA is timely. While past reviews have examined the epidemiology of HIV in different key populations in the region [11,12], there is no comprehensive literature review that has synthesized information on risk behaviors of young people specifically. The purpose of this scoping review is to establish the epidemiological HIV risk factors and underlying risk context for youth residing in or originating from MENA. Such undertaking should help shed light on existing gaps in the literature and provide evidence to inform the development of interventions targeting this group.

Methodology
Our review of the literature was guided by the scoping review methodological framework developed by Arksey & O'Malley [13]. We used PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation in developing our protocol [14]. The final protocol is available on request from the corresponding author. The purpose of scoping reviews is to characterize the breadth of the existing literature on a given topic and as such, they lend themselves to broad research questions [15]. Our research question was thus broadly identified as "what is the volume and scope of available information on risk behaviors of youth from the MENA region and what are the research gaps in the current evidence-base?"

Search strategy
To identify potentially relevant documents, the following bibliographic databases were searched from 1990 to September 10, 2019: MEDLINE, EMBASE, PsycINFO, CINAHL, Web of Science, Cochrane Library. The search strategies were drafted by an experienced team member [DG] and further refined through team discussion. The final search strategy for Medline can be found in S1 Table. The final search results were exported into EndNote, and duplicates were removed. The electronic database search was supplemented by Google Advanced Searches on November 12 th , 2019, using combinations of search terms HIV and (youth or young or student or adolescent) with MENA country names. First author and Principal Investigator [RKH] along with senior author [ML] screened the first 200 results of each of these Google Advanced searches. To maximize identification of relevant articles, we additionally reviewed reference lists of select studies and systematic reviews.

Inclusion/exclusion criteria
To be included in the review, articles needed to address the issue of HIV risk among youth residing in or originating from the MENA region. For the purpose of this scoping review, MENA was defined as the following: Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates (UAE), and Yemen. Peer-reviewed journal articles as well as published reports and conference abstracts were included if they were: published between the period of 1990-2019, written in English, French or Arabic; and provide a separate analysis for participants in the age group 16 to 29. Studies were excluded if they focused on one of the following (unless related to HIV/STI risk): incidence or prevalence of a disease; clinical trials; HIV/STI treatment regimens; drug use; sexual abuse, coercion, harassment, violence; clinical investigations; sexual function; mother to child transmission of HIV; cost effectiveness or cost assessment.  [ML]. Data was abstracted on a variety of study characteristics such as: study jurisdiction; publication type (peer-reviewed journal, report, conference abstract); number of participants within our age range of interest (i.e. 16-29 years); age and sex of participants; outcome definition used in the study; factors associated with risk behaviors; main findings related to the HIV/STI risk behavior.

Data synthesis and analysis
We did not assess risk of bias or appraise quality of the articles, per guidance on scoping reviews [13]. We organized our analysis by population groups, emphasizing the key populations at risk of HIV and other groups most frequently featured in the literature such as prisoners, truck drivers, and street children. When available, we presented estimates for risk behaviors that were specific to the age range of interest.
The remaining 57 studies were considered eligible for this review. These were 52 peerreviewed journal articles four reports which mainly covered HIV risk behaviors among key and bridging populations, and one conference abstract (Table 1).

Youth who inject drugs
Eleven articles investigated risk behaviors of injection drug users among participants who fell in our age range. Most research studies were conducted in Iran, two were conducted in Lebanon, and one was conducted in Egypt (Table 1). Understanding the social determinants of risky sexual behaviors is important among youth who use drugs. Cross-sectional data analyzed from the HIV Behavioral Surveillance among PWID, conducted from 2013 to 2014 in Kermanshah, Iran with additional data collected via in-depth interviewing, found that PWID who reported having multiple sex partners with inconsistent condom use were more likely to experience poly-drug use, being of low socioeconomic and education level, and refuse to attend harm reduction programs [16]. While there is no exact data on the number of people injecting drugs that fall in the age range 16 to 29, a significant proportion of injection drug  Youth engage in sexual activity outside marriage to challenge the culture, financial constraints and inability to marry, basic human need, personal pleasure, suppression, to kill boredom, and to prove manhood.
(Continued )  [17]. Similarly, a study in Southern Iran found that the mean age of first substance use among a group of people at Drop-in Centers was 20.24 ±6.11 [18]. In a study conducted in Lebanon in 2010, 60.76% of PWIDs stated they were at or below 25 years of age when they started injecting drugs [19]. Multiple HIV risks. Youth who inject drugs tended to have a significantly higher probability of having multiple HIV risks compared to their older counterparts. Studies reveal a generally high-risk context, in which young PWIDs engage in multiple risk behaviors such as sharing needles/syringes, using non-sterile injecting equipment, partaking in inconsistent condom use, selling sex for money or favors, and having multiple sexual partners [19][20][21]. Also, HIV/HCV co-infection was associated in Iran with being divorced, having tattoos and past incarceration history [22].
In a national bio-behavioral surveillance survey conducted in 2013 in Iran, Khajehkazemi et al. [23] found that the most common risk behavior among people who inject drugs was use of a non-sterile needle (37%), followed by selling sex for money (30.4%). Moreover, around 13.0% of the sample had practiced shared injection, and only 38.3% used a condom at last sexual intercourse. In Lebanon, Mahfoud et al. [19] state that one fifth of their sample reported sharing needles during their last injection and half of PWIDs stating they had ever bought sex. With respect to condom use, less than half of the 81 PWIDs surveyed reported using a condom the last time they had sex with either a regular noncommercial sex partner or a non-regular noncommercial sex partner. Similarly, in Egypt, PWIDs practiced multiple risk behaviors, most commonly sharing needles (40.5% in Alexandria and 23.0% in Cairo) and inconsistent condom use with regular noncommercial sex partners (3.0%), and non-regular noncommercial sex partners (30.4%) [24]. While another study in Tehran reported multiple risk behaviors among PWIDs, with inconsistent condom use at 55.0%, and receptive and distributive needle sharing at 32.0% and 15.0% respectively, concomitant alcohol use was found to significantly exacerbate prevalence of risk behaviors [25].
Moreover, there was ample evidence for heterogeneity in overlapping risk among PWIDs. For example, in Lebanon, over half of the 81 PWIDs surveyed stated they had ever bought sex and 12.0% had sold sex [19]. In Iran, about one third of the sample of 2290 PWIDs reported selling sex for money [23].

Young men who have sex with men
Sixteen articles focused on MSM who fell in our age range. The evidence demonstrates that young MSM in the region engage in risky behaviors including condomless sex, multiple and concurrent sexual partnerships, transactional sex and concurrent injection drug use. Countries such as Lebanon, Egypt, Libya, Jordan, and Syria reported the riskiest behaviors relating to access to HIV testing, number of sexual partners, and frequency of injection drug use (Table 2).
Lebanon was heavily represented in the evidence-base on MSM risk behaviors in the region with eight out of the 16 articles conducted in Beirut. Studies indicate that MSM are sexually active and engage in multiple risk behaviors at an early age with 52.0% of MSM reporting having initiated sexual activity under the age of 18 [19]. Table 3 describes average age at sexual debut for different population groups.
Risky behavior. Condomless sex was very common across studies in Lebanon [19,[26][27][28][29][30][31][32]. Ghanem et al. [26] found that among the 176 MSM reporting having anal sex, 48.9% did not use condoms during sex in the last three months, and 17.0% of those reported unprotected sex with a partner who had HIV or whose status was unknown [26]. Echoing these findings, Wagner et al.
[32] examined trends in condom use among MSM finding that 45.8% of MSM in their 2017 sample reported sex without a condom and 17.3% reported unprotected sex with an HIV-positive or unknown status partner. However, earlier studies suggest that condomless sex was considerably more common in the MSM community compared to more recent studies. For example, Maatouk et al. [27] found that 58.1% of participants reported unprotected anal sex and in another 2014 study, Wagner et al. [30] found that nearly two-thirds (64.0%) of MSM reported any unprotected anal intercourse with men in the prior 3 months, 23.0% of whom reported unprotected anal intercourse with HIV positive or unknown status partners. Examining condom use by type of partner, Mahfoud et al. [19] found that condom use every time they had sex was more common among MSM engaged in sexual intercourse with regular non-commercial partners (63.0%) compared to those with non-regular noncommercial sex partners (39.0%).
Similar patterns were noted in other countries. In a study in Libya, 21.0% of MSM only reported using condoms during their last anal intercourse [33]. Another study in Morocco with 669 MSM revealed that condomless sex with a commercial partner was practiced by 41.0% of MSM and 53.5% reported not using condoms with a regular male sex partner [34]. In Jordan, consistent condom use was very low at 10.0%, only 27.0% reported having used a condom at last intercourse, and almost one fifth of the sample reported never using condoms during sex [35]. Condomless sex was similarly common in Egypt with between the range of 19.2% and 51.0% of MSM in Cairo, 34.4% in Alexandria, and 22.0% in Luxor reporting condom use during commercial sex [36,37]. In Yemen, condomless anal sex was very common, with 80% reporting not using condoms in their last anal intercourse [38]. MSM with female partners. Across MENA countries, most MSM reported having female sexual partners. In Libya, less than 70.0% of MSM had sex with females through spousal and non-spousal relationships, and in the past six months, around half reported having intercourse with a woman [33]. In Morocco, most participants reported being bisexual and a larger proportion reported having sex with women (81.0% in Agadir and 83.0% in Marrakech). A little less than half of participants reported using condoms with female partners [34]. In Egypt, sex with females was less common at 40.0% in Cairo, but was very high in Alexandria and Luxor,  Lebanon [27] revealed that concurrent drug and alcohol use before and during sex was common at 41.9%, and another found that alcohol was available at 94.0% and multiple substances were available at 33.3%of group sex events in which MSM engaged [28]. Concurrent injection drug use appears to be low among Lebanese MSM, however, with less than 2.0% of MSM in one study reporting having ever injected drugs [28].
Commercial sexual activity was also common. In Morocco, while less than one fifth of participants reported paying for sex, 65.6% reported receiving money or gifts for sex [34]. Commercial sexual activity among Egyptian MSM was also common, at 33.2% in Cairo, 31.8% in Alexandria and a staggering 92.0% in Luxor [24,36]. In Yemen, respondents reported having an average of 2.9 commercial partners to whom they sold sex and an average of 3 partners from whom they bought sex [38]. In Libya, anal intercourse with a commercial partner was practiced by 27.0% of the sample in the past six months and less than one in five of these respondents reported using a condom [33].

Young sex workers
Eleven articles focused on sex workers particularly females who fell in our age range. Five articles out of the eleven took place in different regions across Iran. There was only one study on male sex workers, which was conducted in Lebanon. Studies indicated that sex workers are not yet well studied because they are hard to reach due to the illegal status of their profession and high levels of stigma in MENA [24].
Risky behavior. With respect to condom use, in general, unprotected sex was an alarming risk practice among sex workers. A study in Iran reported that 43.8% of sex workers never used condoms [40]. Similarly, in Syria, condom use in commercial sex was low, as reported by FSWs with 31.3% of participants using condoms every time, 14.2% most of the time and 16.0% sometimes.
[39]. Egypt indicated similar outcomes with only 25.0% reporting condom use in last commercial sex [36].
Results were higher in Iran, Libya and Lebanon. FSWs in Iran using condoms in their last sexual contact with a client ranged between 39.3% and 57.1%, respectively [41,42]. In Libya, 63.4% of FSW reported consistent condom use during sex with one-time clients, and 56.8% during sex with regular clients [33]. In Lebanon, 92.0% of the FSWs stated that they used a condom the last time they had sex with their regular male clients and 98.0% had done so with their nonregular male clients [19]. In another study in Lebanon, focusing on male sex workers, they differentiated between sex workers working in hammams (bathhouses) and escorts [43]. Sex workers from the hammams reported low condom use with clients (one of the nine sex workers consistently used condoms) while the majority of the escorts (five of seven) reported always using condoms with their clients as they are more educated and had higher HIV risk knowledge than hammam sex workers.
Generally, sex workers typically opted not to use condoms with non-client sex partners, in an effort to differentiate sex for work versus pleasure and was less than what is reported previously with paying clients [19,43]. However, condom use was still significantly higher amongst sex workers with non-client sex partners in both Lebanon and Iran [19,41], as opposed to Egypt and Syria [36, 39] but not as high with paying clients [19,36,39,41].
HIV testing. HIV testing among this group varied significantly. In Libya, 38.6% of FSWs had been tested for HIV during the past year and knew the result [33]. Similar patterns were noted in Syria where only 35.3% indicated that they have ever tested for HIV/AIDS, among which only 22.8% were voluntarily tested [39]. Testing was much lower in Iran where only 8.0% of FSWs had been tested [44]. In Egypt, only 2% of the sample of the study were ever tested [36]. On the other hand, HIV testing in Lebanon was highly prevalent as 79.0% of the FSWs were tested [19]. Among those who had tested previously, 86.0% of the FSWs had taken the HIV test as part of a mandatory requirement since 80.0% of the sample are non-Lebanese and are expected to be tested in order to obtain residence or a work permit [19].
Overlapping risk. Regarding drug use, results again varied widely. In Sajadi et al. study [41] in Iran, 73.8% of FSWs reported a history of any drug use (Table 4). Of these, 63.2% were active drug users. Similar results in Iran were confirmed in the Ramzani Tehrani et al. study [44]. High numbers were also detected in Egypt where over half of FSWs reported ever abusing drugs and 6.0% reported injecting drugs in the past year [24]. Libya and Syria showed different patterns as only 3.0% of FSWs in Libya [33] ever injected drugs and 11.0% of FSWs in Syria indicated drug use [39] ( Table 4). Table 4. Risky behaviors among sex workers in the MENA region.

Injecting Drugs
A total of 73.8% reported a history of any drug use. Of these, 63.2% were active drug users.

Students, general population and others
University students. Seven articles explored HIV-related risk factors among university students within the indicated age range, with four articles coming mainly from Iran [45][46][47][48], two from Lebanon [49,50] and one from Egypt [51]. History of high-risk behaviors among university students included having multi-sex partners, having unsafe sex, drug use, alcohol consumption and being in the company of friends who engaged in heterosexual intercourse and were alcohol consumers, were fairly common [45][46][47][48][49]51]. It was also more likely for male students to engage in risky behavior than their female counterparts [47,49,51]. In Iran and Lebanon, students who shared homes with each other are more likely to belong to social networks of people with high-risk behaviors and drug abuse compared to those who live with their families [48,49]. Not discussing their sexual activity preferences with partners, in Lebanon, was associated with increased odds of not knowing about the effectiveness of condoms at preventing HIV [50]. A significant percentage (30.0%) of students in Egypt lacked adequate knowledge about HIV [51]. Also, low level of perceived susceptibility to be infected by HIV virus was common among university students which indicated that the students feel low risk or probability of being infected by HIV virus in the future [45,46,51].
General population and others. Regarding other bridging populations, twenty-two articles within the indicated age range included prisoners, street children, truck drivers, tourist workers, transgender women, conscripts and people of the general population. Participants in this group again had a limited understanding of HIV, especially around modes of transmission and the fairly high-risk behavior [44,[52][53][54][55][56][57][58].
For example, among tourism workers in Egypt, 69.2% knew the magnitude of the problem of HIV and 60.6% reported it was likely to get worse in the future compared to 58.0% and 53.4% respectively among industrial workers [59]. Rate of condom use is low among the general youth population, especially in Egypt, Iran, Iraq, Lebanon, and Palestine [24,55,[60][61][62][63][64][65] and as seen in Table 5.
Among street children in Egypt who have sex, most never used a condom at all and most had multiple sex partners [66]. Condom use is more common among men, especially those who practice extramarital sex in Egypt, Iran, and Morocco [23,24,60,62,64,67] and more frequently used among older children as opposed to those who are younger in age [64,68]. It is worth noting that weakened religion among youth in Libya [53], Morocco [69], and Southern Iran [60] was reported to be one of the factors causing street children to engage in risky behaviors.
Testing was limited among the general population as indicated by multiple studies with the highest rate being in Iran at 23.2% [44,60,62]. Among transgender women in Lebanon, only 43.0% of participants had been tested for HIV within the last 12 months, whereas 40.0% had never been tested [70]. In both Lebanon and Iran, studies reveal that condom use is very limited in this group, reaching 43.0% and 13.3%, respectively [70,71].

Discussion
To our knowledge, this scoping review is the first to examine epidemiological HIV risk factors and underlying risk context for youth residing in or originating from MENA. Even though we are more than three decades into the HIV epidemic, our findings indicate that key populations engage in multiple risk behaviors that could potentially spread further the epidemic in the region despite its low prevalence [8]. Among PWIDs, all evidence consistently indicates that HIV has already established itself among a number of PWID populations in MENA [8]. Therefore, further research as well as HIV testing are needed to understand the magnitude and potential spread of HIV across this key population. The levels of risky behavior practices, such as the use of nonsterile injecting equipment, inconsistent condom use and selling/buying sex have been documented as significant, confirming the potential for further HIV spread among PWIDs. Availability, access and increasing awareness towards harm reduction services are crucial in addressing the high-risk context affecting this key population.
Regarding MSM, they are considered one of the hardest groups to reach given the severe stigmatization they are usually subjected to [8]. However, Lebanon seems to be standing out especially considering the availability of information on this particular group in the country and the relatively high HIV testing trends among them. Across all MENA countries that studied the matter and are included in this scoping review, it is evident that low condom use is very common within this key population and thus, special attention needs to be given with regards to increasing awareness and access to condom use. Also, definitive data are still too limited to document trends on MSM, especially in Iran. MSM remains to be a key population that requires special attention in the MENA region.
The illegal status of sex work in most countries and their young age at first sexual intercourse for profit (Table 3) may have limited the accessibility to HIV awareness and messages which would, thus, allow more spread of the epidemic. Comparing them to other key populations, condom use among sex workers could be considered higher, especially in Lebanon. However, migrants and refugees who engage in such practices may require more exposure to information and services on harm reduction as they are particularly a vulnerable group who may not own the sufficient knowledge on HIV prevention and protection. Also, delaying the average age of first sex for profit generally may contribute to the increased awareness and limited involvement in risky behaviors [46]. Multi-sex partners, having unsafe sex, drug use, alcohol consumption and belonging to a social network practicing risky behaviors are valid reasons for putting university students at a high risk for contracting HIV. Despite their high education, some lacked adequate knowledge on the matter which thus, does not inform their attitudes and leads to a low risk perception. It is also worth noting that young people are disproportionately affected by political instability and war which is prevalent in the MENA region and may have enhanced their vulnerability to drug use [53].
With the youth and bridging populations, peer pressure and young people's inhibition about discussing sexual and reproductive health matters with credible sources are also a few of the factors underlying low utilization of condoms. Gender and age factors as well as adoption of more liberal lifestyles in some settings are potential contributors to this pattern as well [72]. The evident reluctance to access services especially HIV testing needs to be addressed. Moreover, special attention needs to be given to trans-gendered women who engage in high-risk behavior, especially due to the current dearth of the literature involving this population which may hamper the implementation of policies and programs. However, increased awareness alone is insufficient as mentioned earlier. A qualitative study involving five focus group discussions and 15 in-depth interviews conducted in Aden, Yemen examined the role of peer educators in addressing risk behaviours in MENA [73]. The study revealed key enabling factors that facilitated the implementation of a community peer education program for youth HIV prevention in four poor and vulnerable areas of Aden, Yemen, resulting in improved HIV knowledge and risk perception and decreased stigma and risky behavior. An approach that involves community participation, mobilization of targeted communities, and capacity building of all those included may be necessary to change risk context in the MENA [73].

Limitations
We recognize several limitations in our scoping review. First, limitations in the literature due to heterogeneity in risk behaviors and risk contexts that characterize the MENA region makes it difficult to generalize the findings of these studies. Second, our process of selecting articles and literature that meet the inclusion criterion related to age is not perfect. The lack of homogeneity in studies conducted in MENA, often due to limited funding resources, makes it especially hard to locate studies entirely focused on youth.
Reporting of results in these studies is often not homogenous which makes it harder to get separate breakdown by age in some of the studies. Moreover, the scarcity of bio-behavioral surveys conducted in the region makes it more challenging to have a clearer idea about long term trends. Nevertheless, every effort was made on the part of our team to offset some of these challenges. We extracted information on the full range of participant age, in addition to median/mean in order to see who is most featured in the literature: middle vs later adolescents vs older youth. Only studies with the bulk of the sample clustered between the age range of 16-29 were included. Finally, given that HIV is highly stigmatized in the MENA region and the disclosure of sexual attitudes is considered undesirable, reporting accurate behavioral data may be hindered. Therefore, findings should be interpreted with social desirability bias possibility in mind.

Conclusion
This scoping review shows that there is a predominant lack of research on epidemiological HIV risk factors and underlying risk context for youth residing in or originating from MENA. Despite the heterogeneity in risk behaviors and risk contexts that characterize the MENA region, the information gathered allows for identifying gaps in the research which will inform policies and programs for improving current practices related to HIV transmission among youth in MENA.